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This Personal Information Form is to be used by students to provide personal information necessary to activate insurance coverage. You must complete and submit this form to authorize the use of your information for the purpose of providing your coverage. You will receive an email notification from the Student Benefit Plan Office advising if any applicable fees and/or additional documentation is required to activate your coverage.

Opt In

Student Benefits Plan coverage is provided to eligible students automatically, except in certain circumstances where a student’s enrolment status excludes them from automatic inclusion by the institution or due to a previous waiver on file. To enroll in the Student Health and/or Dental plan(s), complete the sections below and submit this form. Upon approval of your request, you will be advised of
fees owing , documentation required and payment due date, directly by email. All supporting document(s) and fees must be received by the applicable deadline in order for the enrolment process to be completed.

PLEASE NOTE: ELIGIBLE STUDENTS ARE AUTOMATICALLY CHARGED FOR THE HEALTH AND DENTAL PLAN, PLEASE CHECK YOUR STUDENT FEES BEFORE FILLING THIS FORM OUT.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

MaleFemale

Date of Birth

Date Month FieldDate Day FieldDate Year Field

Phone Number

Phone Area NumberPhone Local NumberPhone Digits

Program Name

Program Start Date

Date Month FieldDate Day FieldDate Year Field

Opt Out

Already have coverage?

Coordinating multiple plans: If you are an eligible student and have comparable coverage you may wish to coordinate your plans. Benefits under the two plans can be coordinated to increase your coverage up to 100% of the actual expense(s) incurred. For example, following payment under this plan you can submit outstanding balances to the other plan for consideration. Find out more about coordination of benefits.

Opting Out of coverage: If you are an eligible student and have comparable health and/or dental coverage you may apply to opt-out of the plan(s). Each student is given one opportunity to opt-out of the health and/or dental plan(s) each year. All opt-out forms must be completed online or through the Student Benefits Plan Office and must be received within 30 days from the start date of your full-time program. You will not be able to opt-out of coverage at any other point during the school year. NO EXCEPTIONS will be made if the deadline is missed. It is the student's responsibility to pay the plan fees, should they miss the applicable opt-out deadline.

Approval of your opt-out will result in the plan fee being credited. Once your opt-out has been accepted, it will remain in force as long as you remain an eligible student.

Family Add On

Coverage provided through the Student Health and Dental plan can be extended to a spouse and/or
dependent(s). To add eligible dependent(s) complete the sections below and submit this form. You will then be contacted by the Student Benefit Plan Office, via an email notification, of any required supporting documents and fees. All supporting document(s) and fees must be received by the applicable deadline in order for the family add on process to be completed.

Please read and agree to the Terms & Conditions prior to submitting your online Family Add On form.